Ototoxic Drugs in the Spotlight

Australian Journal of Oto-Laryngology, Jun 2004

An important publication affecting all otolaryngologists and most general practitioners was recently released by the American Academy of Otolaryngology - Head and Neck Surgery. The recommendations are destined to be seen as controversial and may not be universally accepted. The Consensus Panel Update on Efficacy and Safety of Topical Antibiotics in the Treatment of Ear Disease was formed to develop a position on the appropriate use of potentially ototoxic antibiotic topical drugs in the treatment of ear disease. The panel stated that the topic of ototoxic, ototopical medication was revisited because of an increase in claims against US physicians related to alleged iatrogenic ototoxic injury in addition to other countries having already developed recommendations on the use of potentially ototoxic medications. Notably, non-ototoxic drugs are now available in many countries including Australia.

The study was extensive and designed to create an "evidence-based review". These reviews, popularised by Cochrane, analyse published literature and grades the evidence based on quality of methodology and reporting.

The panel unanimously agreed on five major recommendations that will affect all clinicians involved in treating ear disease. The recommendations were:

1. When possible, topical antibiotic preparations free of potential ototoxicity should be used in preference to ototopical preparations that have the potential for otological injury if the middle ear or mastoid are open.

2. If used, potentially ototoxic antibiotic preparations should be used only in infected ears. Use should be discontinued shortly after the infection has resolved.

3. If potentially ototoxic antibiotic drops are prescribed for use in the open middle ear or mastoid, the patient/parent should be warned of the risk of ototoxicity.

4. If potentially ototoxic antibiotic drops are prescribed, the patient should be specifically instructed to call the physician or return to the office if the patient develops dizziness, hearing loss or tinnitus.

5. If the tympanic membrane is known to be intact and the middle ear and mastoid are closed, then the use of potentially ototoxic preparations present no risk of ototoxic injury.

We live in a global Otolaryngology community. Recommendations made in any country will be received in Australia almost immediately because of rapid access to information. At present, there are no recommended guidelines established in Australia on this matter, ototopical antibiotics suitable in the middle ear are not available, and it is likely that only a few Australian otolaryngologists are strictly practicing in this way. The recommendations made by this consensus committee raise a number of important questions including the increasing need for Australian otolaryngologists to be involved in evidence-based guidelines in otolaryngology. This is a time consuming and costly exercise but has the potential to radically affect clinical and medicolegal matters. Australian clinicians should be making recommendations based on international evidence but including experience that is uniquely Australian and appropriate to the diverse requirements of the population.

Evidence-based guidelines are now part of clinical practice. However, there are still many clinical dilemmas that will not be solved by broad guidelines. Welltrained and experienced clinicians will always be the mainstay of clinical practice but integrating current best evidence is now important in modern medicine. The next decision is how we shall use these recommendations.

Graeme Clark - Surgeon Scientist

This year Graeme Clark was awarded the highest civil honour, the Companion of the Order of Australia (AC), for services in medicine and to science through innovative research to further the development of cochlear implant technology for world-wide benefit. Graeme has made an everlasting contribution to international otolaryngology and the profoundly deaf. His achievements are widely respected throughout the medical profession and last year he was awarded an Honorary Fellowship of the Royal Society of Medicine in London.

Australian research in otolaryngology is appreciated around the world because of his pioneering efforts. Graeme Clark commenced basic research in 1967 and has led research in the Department of Otolaryngology at the University of Melbourne since 1970 resulting in a multiple-channel cochlear implant that can now provide significant understanding of speech for severely and profoundly deaf children and adults. He persisted despite early criticism from otolaryngologists and scientists. These shortsighted criticisms were described in his book, "Sounds from Silence", where he also revealed the will required to achieve scientific success in the world of clinical otolaryngology.

He has become a celebrated and prominent Australian.

Young otolaryngologists now have the opportunity to combine the Fellowship of the Royal Australian College of Surgeons with a University higher degree based on research. This innovative program is named "Surgeon Scientist" and has attracted some of the best young trainees. However, this pathway needs more help and encouragement from the College and Australian otolaryngologists. Graeme Clark provides a wonderful example for these young surgeons of the future.